A patient is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the transfusion, the patient develops chills, lower back pain, and a fever of 38.9°C. What is the first nursing action?

Question

A patient is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the transfusion, the patient develops chills, lower back pain, and a fever of 38.9°C. What is the first nursing action?

BlackTom AI · Accepted Answer

An acute hemolytic transfusion reaction is most likely: stop the transfusion immediately and escalate to the medical team.

1) Relevant knowledge points and concepts
- Signs developing within minutes (fever, chills, and lower back/flank pain) are classic for an acute hemolytic transfusion reaction (AHTR), often due to ABO incompatibility. This is a potentially life‑threatening emergency that can cause intravascular hemolysis, hypotension, disseminated intravascular coagulation, acute renal failure, and shock. Standard transfusion protocol mandates immediate cessation of the blood product at any suspected severe reaction.

2) Step‑by‑step reasoning process
- Recognize: new onset chills, fever (38.9°C), and lower back pain 15 minutes after PRBC start = red flag for AHTR.
- Immediate first action: stop the transfusion to prevent further introduction of incompatible blood and ongoing hemolysis.
- Next actions (performed after stopping): keep IV patent with normal saline via new tubing, clamp and label the blood bag, notify the medical team and blood bank, obtain blood and urine samples as ordered, monitor vital signs and urine output, and follow institutional transfusion reaction protocol.

3) Calculations
- No numeric calculations required for this clinical decision.

4) Why this answer is correct
- Stopping the transfusion immediately halts further exposure to the offending blood product and is the single most important initial intervention to reduce morbidity and mortality. Escalating to the medical team/blood bank initiates the investigation and treatment pathway.

5) Why other options are incorrect
- Slowing the rate or continuing risks ongoing hemolysis and harm. Administering paracetamol masks fever and does not address the underlying life‑threatening process. Positioning for pain does not stop the causative exposure nor prevent progression.

6) Conclusion
- The correct first nursing action is: Stop the transfusion immediately and escalate to the medical team, which matches the provided answer.

A patient is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the transfusion, the patient develops chills, lower back pain, and a fever of 38.9°C. What is the first nursing action? 单项选择题

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